Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate fall prevention interventions for a resident with dementia, a pressure ulcer, and type 2 diabetes, who was identified as a high fall risk. The resident required staff assistance for activities of daily living and transfers, and her care plan specified that her wheelchair should not be within reach to prevent unsupervised transfers. Despite these documented needs, the resident's wheelchair was repeatedly found at her bedside, enabling her to attempt self-transfers without supervision. On two separate occasions, the resident was found on the floor in her room, having attempted to transfer herself from bed to wheelchair. Staff interviews confirmed that the resident was known to attempt unsupervised transfers and that her wheelchair should have been kept out of reach, but this intervention was not consistently implemented. Observations revealed that staff were unaware of the resident's fall and did not respond until prompted by a state surveyor. Additionally, the facility's fall prevention policy required assessment and documentation of fall risk and implementation of interventions, but there was no documentation of specific interventions related to wheelchair placement in the resident's medical record. The facility failed to follow its own policy and did not ensure adequate supervision or environmental controls to prevent accidents for this high-risk resident.